Approximately 12% of people in the United States suffer from migraine; with 1 in 4 households containing a person with migraine.1-3 Characterized by episodic attacks of moderate to severe head pain with associated symptoms of nausea, vomiting, and sensitivity to light and sound, migraine is the most disabling neurologic condition worldwide.4,5 Because migraine is most prevalent during the peak years of productivity, these high rates of disability are particularly problematic in terms of occupational and household functioning.6 Migraine contributes to both missing work (absenteeism) and reduced functioning while at work (presenteeism).7

Cognitive difficulties during migraine may contribute to the high rates of burden in occupational and household functioning. Existing evidence suggests that, during a migraine episode, some people with migraine appear to experience mild transient reductions in cognitive functioning.8 This could be particularly problematic for adherence to acute migraine management strategies, as acute management of migraine is a cognitively demanding task. People with migraine must attend to a variety of sensory stimuli, sort symptoms into headache categories, track symptoms over time, and make in-the-moment decisions regarding acute migraine medication and non-pharmacologic management options to effectively manage migraines.9,10

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Developing individualized decision support tools to help patients with migraine decide which acute treatment strategy to use with any given symptom profile may be particularly important when patients describe transient ictal cognitive difficulties.11 These further highlight the importance of reducing migraine frequency in people with migraine.

Some people with migraine have described difficulty thinking between migraine episodes, but evidence regarding interictal cognitive dysfunction is inconsistent.12 It is possible that migraine accounts for some persistent cognitive dysfunction in certain people with migraine; however, non-migraine phenomena likely account for some of the variation in the findings. Certain preventive migraine medications could contribute to cognitive difficulties.13 It is also possible that a cycle of fear of pain and avoidance of perceived triggers contributes to interictal cognitive difficulties in people with migraine.

This episodic symptom presentation distinguishes the patient experience of migraine from the patient experience of many other chronic diseases. A person with migraine may live most of his or her life symptom-free; however, on occasion, the person with migraine is often unexpectedly in significant pain and nauseated and/or vomiting, and routine sensory experiences are noxious. It is no surprise that people with migraine, as well as clinicians and researchers who work with migraine, expend a great deal of time and effort on identifying factors that may trigger migraine episodes. However, it is unclear to what extent triggers identified by patients reflect accurate migraine-triggering factors.14,15 Further, evidence suggests that fear (and subsequent avoidance) of triggers may be counterproductive in the management of migraine, and could contribute to migraine-related disability.16-18

Understanding the Source of Cogniphobia

The fear-avoidance cycle is a well established phenomenon whereby the fear of an aversive experience, such as migraine, leads to the avoidance of any behavior or situation believed to be associated with its onset, such as perceived migraine triggers.19 In the context of chronic musculoskeletal pain, people sometimes develop excessive fear and avoidance of movement (“kinesiophobia”), which leads to disuse of major muscle groups, depression, and long-term disability.20 Fear and avoidance also appear to be important in explaining disability in migraine.21 Between migraine episodes, people with migraine fear the next attack, which can lead to excessive worry and avoidance of situations and behaviors believed to trigger migraine attacks. In the long-term, it is plausible that this cycle of fear and avoidance could lead to hypervigilance to perceived migraine triggers, increased depression and anxiety, and disability associated with excessive reduction in the scope of typical daily activities.

Cognitive exertion (“thinking too hard”) is perceived by some patients to trigger migraine episodes.22 Cogniphobia refers to the fear, and subsequent avoidance, of cognitive exertion in people with migraine because it is believed to trigger migraine episodes. Although initially observed in a post-traumatic headache disorder population,23 cogniphobia has also been observed in primary headache disorder populations.24,25

In 74 young adults with migraine and/or tension-type headache, greater cogniphobia was associated with greater pain catastrophizing, as well as greater anxiety and avoidance of pain.24 In 80 patients with migraine who presented at a specialty care headache center, greater cogniphobia was associated with greater levels of maladaptive headache-related beliefs and a greater number of endorsed anxiety symptoms.26 This is consistent with the broader literature on the fear-avoidance cycle: people with migraine who hold beliefs that cognitive exertion is potentially harmful, and who subsequently avoid cognitive exertion, appear to be more likely to focus on their pain, believe that their pain is uncontrollable, and experience higher rates of anxiety, particularly related to pain.

Cogniphobia is a relatively novel concept within the field of headache that bears further investigation to understand its prevalence and impact, as well as methods to mitigate cogniphobia in people with migraine. It is possible that fear and avoidance of cognitive exertion could interfere with day-to-day decision making related to migraine management, reducing the clinical outcomes of acute migraine treatments in individual patients.

More broadly, thinking is central to everyday functioning. People with migraine who exhibit cogniphobia may reduce their engagement in cognitively-demanding tasks at work, school, and at home. In time, this could lead to self-selection of career tracks that are less cognitively demanding, or even potentially self-removal from the workforce. Preliminary evidence suggests cogniphobia is associated with higher rates of disability, particularly as it relates to occupational functioning.27 Further evaluation of the real-life implications of cogniphobia in people with migraine will shed light on the impact of this phenomenon. Evidence from the chronic pain literature suggests that fear and avoidance beliefs are modifiable28; future work should extend this literature to examine interventions to reduce cogniphobia in people with migraine. 

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This article originally appeared on Neurology Advisor